CPM Fall 2019 - 9

daup h i n c m s .o
.o rg

n a poll not long ago, doctors were asked
to pick what medication they would bring
to a desert island if allowed to choose
only one. The overwhelming answer was
aspirin. Besides lowering fever and reducing
pain, it has long been known to lower rates
of heart disease, stroke and colon cancer.
Recently, some newer studies have contradicted the claims of the latter preventive
actions, lending to much confusion on the
part of doctors and patients alike. When
done reading this, you'll hopefully be more
illuminated about the topic, but possibly
more confused about the conclusions.

Acetylsalicylic acid was initially developed
by a French chemist (Charles Frederic
Gearhardt) and two German chemists
(Felix Hoffmann and Arthur Eichengrun)
at the German pharmaceutical company
Bayer. They began selling the product
under the name "aspirin" in 1899, and it
became the world's most used pain reliever
and fever reducer for most of the 20th
century. Because of its anti-inflammatory
properties, researchers began randomized
trials for secondary prevention of heart
attacks in the 1970s. Aspirin inhibits
cyclooxygenase-1, a potent blood vessel
constrictor, and inhibits platelets from
sticking together to cause blood clots in
our arteries. In the 1980s, the Physicians
Health Study found that aspirin reduced
the incidence of first heart attacks by 44%.
However, it did not reduce eventual death
from heart disease, and was largely effective
only when used after the age of 50.

with low-dose aspirin in adults at higher
cardiovascular risks, as long as they do not
have increased bleeding risk.

Who exactly
would be at
higher risk for
bleeding from
aspirin?
* Prior history of GI bleed,
including stomach ulcers
* Heavy use of alcohol,
tobacco or caffeine
* Age over 70 (especially if at
higher risk for falls due to
orthopedic or neurologic
problems)
* Low platelet count
* Hereditary blood clot
abnormalities
* Chronic kidney disease
* Concurrent use of other
medications that increase
bleeding risk, including
anti-inflammatory pain
relievers, steroids,
warfarin, and other
"blood thinners."

vascular events, but also caused increased
major bleeding. The ARRIVE study (Lancet,
volume 392) looked at non-diabetics with
elevated overall cardiovascular risk, and a
mean age of 64. It did not show benefit
over placebo. Lastly, a meta-analysis (study
of studies) of these three articles with ten
earlier studies did show an overall benefit
of aspirin for cardiovascular outcomes, but
increased the risk of bleeding.
What about secondary prevention...
people who already had a heart attack
or stroke, and need to prevent a second
one? Multiple studies by expert cardiology
organizations show benefit of aspirin for
heart attack, chronic stable angina, unstable
angina, following coronary bypass surgery,
following coronary stenting, following
carotid artery clot removal, and for stroke/
ministroke. In the last four conditions, the
drug clopidogrel (Plavix) was also advised
for variable time periods.
If you are wondering whether aspirin
might improve your health, and you're not
in a clear category based on the information
described above, a helpful decision tool
at www.aspiringuide.com can assess your
personal risk. Otherwise, improve your
chances for a long and healthy life with
a balanced diet, regular exercise, mental
activity, avoiding smoking, limiting alcohol...and drop off any excess donuts
and brownies at my office if you're in the
neighborhood.

To add to the confusion, four large
The current consensus about aspirin randomized trials published in 2018 do
remains favorable overall. The United States not support the USPSTF recommendations.
Preventive Services Task Force most recently The simple reason that they are contraconcluded that aspirin for adults age 50-59 dictory is that they employ variable study
lowered cardiovascular disease risk by at designs and studied patients with different
least 10% over 10 years. Additionally, it also inherent risks. The ASPREE study (New
slightly lowered colon cancer rates. In adults England Journal of Medicine, volume 379)
60-69, studies are less conclusive, so patient studied older patients with a median age of
preference plays a great role. Above age 70, 74. Compared to placebo, aspirin did not
protective evidence was inconclusive, due to significantly reduce cardiovascular disease
higher risks of bleeding. Supporting these events, but did increase the risk of bleeding
conclusions, the 2019 joint decision of the and overall death. The ASCEND study (in
American College of Cardiology and the the same journal issue) involved diabetics
American Heart Association strongly rec- with a mean age of 63. Compared to plaommend primary heart disease prevention cebo, aspirin caused lower rates of serious
Central PA Medicine Fall 2019 9

http://www.dauphincms.org http://www.aspiringuide.com

CPM Fall 2019

Table of Contents for the Digital Edition of CPM Fall 2019